Traditionally, healthcare claims adjudication systems provision for separate payments to each healthcare service provider for the individual services they provide to a patient for an illness or during the course of treatment. This approach can result in fragmented care with minimal coordination across healthcare service providers and healthcare settings. In such cases, payment is based on a number of services offered by the healthcare service providers rather than the quality of care provided to patients.
Conventionally, in a bundled payment approach, all services related to an episode of care by healthcare providers (e.g., physician, surgeons, post-acute care providers) are reimbursed via a single payment. An entity financially at-risk for managing the bundled payment, herein referred to as the episode underwriter, receives a fixed, lump-sum payment from a payor, such as a health plan or employer group. The episode underwriter then pays for healthcare services consumed by the patient per the episode underwriter's contracted payment rates with the various healthcare providers. Similar to a health plan, the episode underwriter receives as underwriting margin the difference between the bundled payment and the payments made to the healthcare providers. The episode underwriter may be an insurance service provider or may be a healthcare provider, such as a physician group or hospital that desires to take financial risk to manage the episodes.
Traditionally, healthcare claims adjudication systems used by the healthcare providers have been designed to manage the entire healthcare claims of a member and are not well suited to manage bundled payments. Different techniques such as claims accumulators or dummy National Provider Identifier (NPI) numbers have been used to track expenses related to a particular clinical episode. However, such approaches have limitations, such as capturing the relevant claims as defined by the inclusion criteria parameters of a particular clinical episode, including but not limited to the relevant diagnoses, relevant procedures, relevant diagnostic related groups (DRGs), length of episode, and the network of providers. Additionally, determining the eligibility of the patient for bundled payment and determining patient responsibility have proven difficult with traditional healthcare claims adjudication systems. Moreover, the current healthcare claims adjudication systems are person dependent and require training and compliance with alternate adjudication methods, and are highly fallible and require significant reconciliation process after the episode.
In view of the above, there is a need for an automated bundled payment adjudication system that obviates the disadvantages of the existing healthcare claims adjudication systems, along with providing other benefits.